18D-040 (6)375 KING ST - PRIDE BP -2019-0718
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 040 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP -2019-0718
Project # JS -2019-001177
Est. Cost: $15000.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT BOLDUC 038811
Lot Size(sq. ftp: 42209.64 Owner: Pride Convenience Inc
Zoning: HB(100)/WP(6) / Applicant: ROBERT BOLDUC
AT. 375 KING ST - PRIDE
Applicant Address: Phone: Insurance:
246 COTTAGE ST (413) 737-6992 Workers Comnensation
SPRINGFIELDMA01104 ISSUED ON:12/20/2018 0:00:00
TO PERFORM THE FOLLOWING WORK. -REMODEL 1,400 SQ FT OF INTERIOR SPACE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace/Chimney:
Insulation:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 12/20/2018 0:00:00 $105.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck — Building Commissioner
File # BP -2019-0718
Q
APPLICANT/CONTACT PERSON ROBERT BOLDUC LIa
ADDRESS/PHONE 246 COTTAGE ST SPRINGFIELD (413) 737-6992 1 { w w
PROPERTY LOCATION 375 KING ST - PRIDE
MAP 18D PARCEL 040 001 ZONE HB(100)/WP(6)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
New Construction
Non Structural interior renovations
Addition to Existina
Accessory Structure
Building Plans Included:
Owner/ Statement or License 038811
3 sets of Plans / Plot Plan
THE FOG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INY9AMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR
Major Project: Site Plan AND/OR
ZONING BOARD PERMIT REQUIRED UNDER: §_
Finding Special Permit
Special Permit With Site Plan
Special Permit With Site Plan
Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official
�2 41
Note:
Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
Version] .7
City of Northampton
Building Department DEC
212 Main Street
Room 100
DEPT OF 13L
Northampton, MA 01 06P NORTHA
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO
/FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by offici
375 KING ST Map ��%> Lot Ow Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
PRIDE CONVENIENCE INC
Name (Print)
2.2 Authorized Agent:
DAVID SABOURIN
Name (Print)
Signature `
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1+2+3+4+5)
Building Permit Number
Signature:
Buildina Commissioner/Inspector of
.246 COTTAGE 3T SPRINGFIELD MA 01104
Current Mailing Address:
i(413) 737-6992
246 COTTAGE ST SPRINGFIELD MA 01104
Current Mailing Address:
(413) 737-6992
Telephone
$5,000.00;
Building Permit Fee
COCheck Number
This Section For Official Use Only
Date
Issued
',���,� SAS ~►,✓ c��t,U# �y/3 X133 'r7ly-z�,
Date
SAB R� r✓ �PR�
570R,65, cowl
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑� Existing Ground Sign ❑ New Signs 0 Roofing ❑ Change of Use ❑ Other ❑
Brief Description REMODEL INTERIOR DUE TO DUNKIN DEPARTURE. CABINETRY, INSTALL NEW EQUIPMENT,
Of Proposed Work: ,KITCHEN HOOD AND SUPPRESION SYSTEM AND SUBWAY. REMOVE NON SUPPORTING WALLS.
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A Assembly ❑
A-1 ❑ A-2 ❑ A-3 ❑
1A
❑
A-4 ❑ A-5 ❑
1B
❑
B Business ❑
2A
213
2C
I
❑
❑
❑
E Educational ❑
F Factory ❑
F-1 ❑ F-2 ❑
H High Hazard ❑
3A
313
❑
❑
I Institutional ❑
1-1 ❑ 1-2 ❑ 1-3 ❑
M Mercantile ❑�
4
❑
R Residential ❑
R-1 ❑ R-2 ❑ R-3 ❑
5A
513
❑
❑✓
S Storage ❑
S-1 ❑ S-2 ❑
U Utility ❑
Specify:
Specify:
M Mixed Use ❑
S Special Use ❑
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Merchantile
Proposed Use Group: Merchantile
Existing Hazard Index 780 CMR 34): 3,,.
Proposed Hazard Index 780 CMR 34): '3
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING
PROPOSED NEW CONSTRUCTION
OFFICE USE ONLY
Floor Area per Floor (so
,,,,.
1S` 4,400'
S(
1 4,400`
2nd
nd
2
3rd
3rd
th -
4
4m
Total Area (sf) 4,400,
Total Proposed New Construction (so
,
4,400:
Total Height (ft) 21
Total Height ft 21
7. Water Supply (M.G.L. c. 40, § 54)
7.1 Flood Zone Information:
7.3 Sewage Disposal System:
Public 0 Private ❑
Zone + , Outside Flood Zone❑✓
Municipal ❑✓ On site disposal system ❑
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 969 acre ..969 acre
Frontage
Setbacks Front
Side L: R::L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW U YES
IF YES, date issued: 02/26/1998
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
IF YES: enter Book 5369 Page; 80 and/or Document # 980011571
B. Does the site contain a brook, body of water or wetlands? NO G) DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ObtainedQ , Date Issued: ;
C. Do any signs exist on the property? YESkv
NO 0
IF YES, describe size, type and location: Ground and Wall Signs
D. Are there any proposed changes to or additions of signs intended for the property ? YES ®i NO 0
IF YES, describe size, type and location: ,Change to face of signs to reflect new tenant/use
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
Not Applicable
Registration Number
Expiration Date
Date
Area of Responsibility
Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Name
Address
Signature
9.3 General Contractor
Name:
Responsible In Charge of Construction
Address
Telephone
Date
Not Applicable El
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Structural Enaineerina Structural Peer Review Reauired Yes %, J No
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
12/17/2018
Signature of Owner Date
DAVID SABOURIN
I, as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
ned under the Dains and oenalties of
Print Name
Siqnature of Owner/Agent Date
I SECTION 12 - CONSTRUCTION SERVICES I
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No 0
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 317,s7 ikivc,
The debris will be transported by: Sj-4=,,.-
The debris will be received by:
Building permit number:
Name of Permit Applicant PP-)T--q520T36d-1T' tBoc (2—
Date Signature of Permit Applicant
The Counitontt-eatlth tq':'1la.sacicusetts
Department of Industrial.•lccideuts
ivi Office offit ve trgaitions
600 1Va0ington .street
Boston, .Moss. 02,11.7
iU14"14�. 11 t aSS. �p 1'/f�E a3
Workers' Compensation Insurance Affidavit: Bit ilders/Contractors/Electricii bers.
A2pllcan.t Information Please Print Le iblv:.._..
ikinae(Business/OrpnintimOndividual):
Address, c'Crr 1.�►�"i"?C.�1S __ ._
City/State/zlp: Phone#: IT3-1757-1d99'R.
Are ygu an employer? Check the appropriate'I
1. Aq am an employer with4. ❑
employees (hull and/or part time).
2. Z 1 am a sole proprietor or partner-
ship tend have no employees
working for me in any capacity.
[No workers' comp. insurance
requirtA 3. D
3. 1 am a homeowner doing all work
myself (No workers' wmp.
insurance required) t
by appomart that choeb tM til frust
I am a general contractor and 1
have hired the sub -contractors
listed on the attached sheet.
'Mm sub- contractors have
employees and have workers'
comp, insurance. t
We are a corporation and its
officers have exercised their
right of exemption pears MGL
c. 152, § 1(4}, and we have no
employees. [no workers'
comp. insurance required.]
workers' compausstton
Type of project (retluii
6. 0 New construction
7.. ► Remodeling
8. t Demolition
9.—! Building addii ion
10. 1 Electrical repairs or additions
11. 7 Plumbing repairs or additions
12..E Roof repairs
13. I either
wks ttubmit ehltt offidoWt tmdiaatbg"ora dolris ailwrrk and tier hire outd4o contractors must submit a new atltdavit iadieattnl such.
wwwwwwwww"."odttld,64i 160" vuwdat este Mame of the sub -coda setnrs and state whether or not those entities have employers. it
JAM an empk)w that JsproA&,g workers' compensatim insurrante for ray employees. Below is the policy and joh site
irrforiatadem
Insurance Company Name: Ar,�m m o -r t V G 5 00
Policy # or Self -ins. Lic. #: WC, tom► +ara-C = OC4 Expiration Date: 1
Job Site Address: city/Statemp:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (date).
Failure to secure, coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a line
up to $1,500.00 and/or one year imprisonment as well as civil penalties in the form of STOP WORK. ODDER and a fine of
$250.00 a day against violator. He*advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for Covera a verification.
I de herby cert rtr the pains
�and pen tlea ofperjury that the information provided above is true and correct.
Date:
Print Name.- iSne-t" Phone #. N13 — rig
Official use only . Do not write to this area to be completed by city or tolvn official i
City, or Torn: Permit/license #:
1
Issuing Authority (circle one):
i.Board of Tleath 2. Building Department 3. Cityll'own Clerk 4. Electrical Inspector 5. Plumbing Inspector
+6. tither
Contact perm: Phone #: !
u